The older adult who is diagnosed with type 2 diabetes mellitus has a sensory impairment and unstable blood sugar levels. Which of the following alterations in sensory function does the nurse address in the plan of care for stabilizing the blood sugar?
Awakens with periodic left-foot numbness
Enjoys spicy food more than bland food
Has difficulty hearing conversations in crowded rooms
Requires reading glasses at 2.0 strength
None of the above
The Correct Answer is A
Choice A reason: Awakens with periodic left-foot numbness is an alteration in sensory function that the nurse should address in the plan of care for stabilizing the blood sugar, as it may indicate peripheral neuropathy, which is a common complication of diabetes. Peripheral neuropathy is a nerve damage that affects the feet and legs, causing numbness, tingling, pain, or weakness. Peripheral neuropathy can increase the risk of foot ulcers, infections, and amputations. The nurse should educate the older adult about the importance of regular foot care, blood sugar control, and medication adherence.
Choice B reason: Enjoys spicy food more than bland food is not an alteration in sensory function that the nurse should address in the plan of care for stabilizing the blood sugar, as it is a personal preference that does not affect the blood glucose levels. However, the nurse should advise the older adult to limit the intake of salt, fat, and sugar, and to follow a balanced and nutritious diet that meets their needs and preferences.
Choice C reason: Has difficulty hearing conversations in crowded rooms is not an alteration in sensory function that the nurse should address in the plan of care for stabilizing the blood sugar, as it is a common age-related change that does not affect the blood glucose levels. However, the nurse should assess the older adult's hearing ability and provide appropriate aids and strategies to enhance their communication and socialization.
Choice D reason: Requires reading glasses at 2.0 strength is not an alteration in sensory function that the nurse should address in the plan of care for stabilizing the blood sugar, as it is a common age-related change that does not affect the blood glucose levels. However, the nurse should assess the older adult's vision and provide appropriate aids and strategies to improve their safety and quality of life.
Choice E reason: None of the above is not the correct answer, as there is one choice that is an alteration in sensory function that the nurse should address in the plan of care for stabilizing the blood sugar.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A: "Client slept throughout the night" - Good sleep can be an indicator of effective pain management. Pain can disrupt sleep, so if the client is sleeping well, it may suggest that their pain is being effectively managed¹.
Choice B: "Client cooperative during AM care" - If the client is cooperative during care, it may suggest that they are not in significant pain. Uncontrolled pain can make people irritable and uncooperative¹.
Choice C: "Client ate 80% of breakfast, 70% of lunch and 100% of dinner" - Pain can affect appetite. If the client is eating well, it may suggest that their pain is under control¹.
Choice D: "Client winces only when turned and repositioned" - If the client only shows signs of discomfort during movement, it may suggest that their pain is generally well-controlled¹.
Choice E: "Client slept during dressing change" - This is not necessarily an indicator of effective pain management. The client could be sleeping due to fatigue, medication effects, or other reasons unrelated to their pain level¹.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: Determining coughing frequency is not a reliable way to assess whether the client has adhered to prescribed therapy, as coughing can have various causes and may not be related to heart failure or its treatment.
Choice B reason: Checking for peripheral edema is a useful way to assess whether the client has adhered to prescribed therapy, as peripheral edema is a common sign of fluid retention and worsening heart failure. If the client has been taking diuretics as prescribed, the edema should be reduced or absent.
Choice C reason: Auscultating the lungs bilaterally is a helpful way to assess whether the client has adhered to prescribed therapy, as lung sounds can indicate the presence or absence of pulmonary congestion and crackles, which are signs of fluid overload and worsening heart failure. If the client has been taking medications to improve cardiac function and reduce fluid volume as prescribed, the lungs should be clear or improved.
Choice D reason: Assessing diet over the last 48 hours is a relevant way to assess whether the client has adhered to prescribed therapy, as diet can affect fluid and sodium intake and retention, which can worsen heart failure. If the client has been following a low-sodium and fluid-restricted diet as prescribed, the risk of fluid overload and dyspnea should be lower.
Choice E reason: Comparing current weight to baseline is an important way to assess whether the client has adhered to prescribed therapy, as weight can reflect fluid status and changes in heart failure condition. If the client has been taking medications and following dietary recommendations as prescribed, the weight should be stable or decreased.
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